Basic Information
| Provider Information | |||||||||
| NPI: | 1578848198 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BRYANT | ||||||||
| FirstName: | PEGGY | ||||||||
| MiddleName: | S | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MSW | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | KIRPATRICK | ||||||||
| OtherFirstName: | PEGGY | ||||||||
| OtherMiddleName: | S | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | MSW | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 510 W 29TH ST | ||||||||
| Address2: | |||||||||
| City: | CHEYENNE | ||||||||
| State: | WY | ||||||||
| PostalCode: | 820012760 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3076329362 | ||||||||
| FaxNumber: | 3076376852 | ||||||||
| Practice Location | |||||||||
| Address1: | 510 W 29TH ST | ||||||||
| Address2: | |||||||||
| City: | CHEYENNE | ||||||||
| State: | WY | ||||||||
| PostalCode: | 820012760 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3076329362 | ||||||||
| FaxNumber: | 3076376852 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/14/2011 | ||||||||
| LastUpdateDate: | 02/28/2012 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
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| AuthorizedOfficialNameSuffix: | |||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 171M00000X | N | Other Service Providers | Case Manager/Care Coordinator | 1041C0700X | 485 | WY | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.